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Sbhatu ' ,�l,U� �i��/zC�i 222 ROSEDALE TOWERS 1700 WEST HIGHWAY 36 SAINT PAUL, MINNESOTA 55113 TELEPHONE 651-633-1039 FACSIMILE ! R E C E I V��633-7393 II APR 18 2013 � April 15, 2013 CITY CLERK � I City Clerk � City Hall � 15 West Kellogg Blvd. , Suite 310 ', Saint Paul, MN 55102 ', Re: Our Client: Senayit Sbhatu ' City of St . Paul Employee: Peter Davis , Date of Accident : 02/Ol/13 � Our File: 21206 ' � Dear Sir or Madam: � i We represent the above named client who was injured in an automobile accident in which your employee and city vehicle were involved on the above date. Enclosed please find the Notice of Claim and executed Notice of Claim form. , ; I have also enclosed a copy of the police report and copies of the photographs of the damage to my client' s vehicle for your review. Thank you and we look forward to hearing from you. V y s, �,�s,.- # - f:��� Robert �Appert RJA/cmk Enclosures NOTICE OF CLAIM IN ACCORDANCE WITH MINDT�SOTA STATUTES SECTION 466.05 (1976) T0: St . Paul Regional Water Services PLEASE TAKE NOTICE That Senayit Sbhatu, at all times material herein resides at 4881 Helena Rd. , St. Paul, MN 55128 . Said party claims damages by reason of bodily injuries while being struck in a motor vehicle accident involving a St. Paul Regional Water Service vehicle in the City of Maplewood, County of Ramsey, State of Minnesota. NATURE OF ACTION That on February l, 2013 Senayit Sbhatu was involved in an automobile accident that was the fault of St. Paul Regional ' Water Services vehicle driven by Peter Michael Davis. That on February 1, 2013 Senayit Sbhatu received injuries to , her neck, back and multiple other injuries. ', That at all times material hereto the above named St. Paul j Regional Water Services and Peter Michael Davis were negligent for failure to maintain a proper look out and maintain proper control of the city vehicle. Due to said carelessness and negligence on the part of the above named Peter Michael Davis and St. Paul Regional Water Services, Senayit Sbhatu has incurred injuries and expenses. APPERT FICE Dated April 15, 2013 B Robert J. per Attorney for Claimant Attorney I . D. No. 02926 222 Rosedale Towers 1700 West Highway 36 St. Paul, MN 55113 (651) 633-1039 NOTICE OF CLAIM FORM to the City of Saint Paul, Minnesota Minnesota State Statute 466.05 states that"...every person...whn claims damages from any municipaliry...shaU cause to be presented to the governing b�dy of the municipaliry within 180 days after the alleged loss or injurv is discovered a notice stating the time,ptace,and circumstances thereof,and the amount of compensation or o�her relief demanded." Please complete this form in its entirety by clearly typing or printing your answer to each question. If more space is needed,attach additional sheets. Please note that you wili not be contacted by telephone to clarify answers,so provide as much information as necessary to explain your claim,and t6e amount of compensation being requested. You will receive a written acknowledgement once your form is received. The process can take up to ten weeks or longer depending on the nature of your claim Tliis form must be signed,and boW pages completed. If something does not apply,write`N/A'. SEND COMPLETED FORM AND OTHER DOCUMENTS TO: CITY CLERK, 15 WEST KELLOGG BLVD, 310 CITY HALL, SAINT PAUL, MN 55102 First Name s�h,��� Middle Initial 1 Last Name .5���Ll. Company or Business Name Are You an Insurance Company? Yes/�If Yes,Claim Number? Street Address 7 � �� ��P,��- �Gf City � • P�.l State MN Zip Code .5S/�� Daytime Phone (_) - Cell Phone( ) - Evening Telephone( ) - Date of Accident/Injury or Date Discovered � � /.3 Time �•�� � am/�m T Please state,in detail,what occurred(happened),and why you are submitting a claim.Please indicate why or how you feel the City of Saint Paul or its employees aze involved and/or responsible for your damages. f''/�t s� t'a.� 2 f � a,s�.� reoo�'�• j � i � P�le�e check the box(es)that most closely represent the reason for completing this form: C�7My vehicle was damaged in an accident ❑ My vehicle was damaged during a tow ❑My vehicle was damaged by a pothole or condition of the street ❑My vehicle was damaged by a plow ❑My vehicle was wrongfully towed and/or ticketed ❑I was injured on City property ❑Qther type of property damage—please specify I ��Other type of injury—please specify In order to process your claim vou need to include copies of all apulicable documents. For the claims types listed below,please be sure to include the documents indicated or it will delay the handling of your claim. Documents WILL NOT be returned and become the property of the City. You are encouraged to keep a copy for yourself before submitting your claim form. O Property damage claims to a vehicle:two estimates for the repairs to your vehicle if the damage exceeds $500.00;or the actual bills and/or receipts for the repairs O Towing claims: legible copies of any ticket issued and a copy of the impound lot receipt O Other property damage claims:two repair estimates if the damage exceeds$500.00;or the actuat bills and/or receipts for the repairs;detailed list of damaged items O Injury claims: medical bills,receipts O Photographs are always welcome to document and support your claim but will not be returned. Page 1 of 2—Please complete and return both pages of Claim Form Failure to complete and return both pages will result in delay in the handling of your claim. All Claims-ulease complete this section Were there witnesses to the incident? Yes No Unknown (circle) Provide their names,addresses and telephone numbers: _,�'ee a-1-�-ac�/nT�/ ���cr t'rT.ontf Were the police or law enforcement called? es No Unknown (circle) If yes,what department or agency? MHP Case#or report# 13 S�b 6 9b S Where did the accident or injury take place? Provide street address,cross street,intersection,name of park or facil'ty, closest landmark,etc. Please be as detailed as possible. If necessary, attach a diagram.(Plc�ast Stt a�.�i��� �JL!SL_y"a110i Please indicate the amount you are seeking in compensation or what you would like the City to do to resolve this claim to your satisfaction. T� �kress oF �So, a o v Vehicle Claims- lease com lete this section ❑check box if this section does not a 1 Your Vehicle: Year �Ob f Make ,� Model License Plate Number State_��C or .S'c/,.� Registered Owner en Driver of Vehicle Area Damaged s City Vehicle: Year c0 Make i ode F.ZS" License Plate Number 93/�S� State�1/�Color Driver of Vehicle(City Employee's Name) � /�?�c�ia�a�r�S Area Damaged In'u Claims- lease com lete this section ❑ check box if this section does not a 1 How were vou iniured?�j `-�'t�t ar�r'��i� What part(s)of your body were injured? Q ui�i� Fcl�cw� Have you sought medical treatment? Yes No Planning to Seek Treatment(circle) When did you receive treatment? c � - i��� (provide date(s)) Name of Medical Provider(s): Address Telephone Did you miss work as a result of your injury? es No When did you miss work? F� '� ct� � h • (provide date(s)) Name of your Employer: Zr� S' ; Address �.�/n `Tc��:S6n _S'�. . S-�. Pav% , Mn/ ,�`S/a / Telephone - /S 7 6d Check here if you are attaching more pages to this claim form. Number of addi�onal pages ��. By signing this form,you are stating that all information you have provided is true and correct to the best of your knowledge. Unsigned forms will not be processed. Submitting a false claim can result in prosecution. Date form was completed Y�/5�--/3 Print the Name of the Person who Completed this Form: l�o��.-f�,pei�. A,��iat.N 1'Di c.'�ari.,�� Signature of Person Making the Claim: - ' f'�' ..� Revised February 2011 Treating Physicians for Senayit Sbhatu Dr. Embaye Nile Chiropractic 2421 7th Street St . Paul, MN 55116 Noran Neurological Clinic 2828 Chicago Ave. , Suite 300 Mpls, MN 55407 St. Paul Regions Hospital (by ambulance) 640 Jackson Street St . Paul, MN 55101 Health Partners - St. Paul Clinic 205 S. Wabasha Street St. Paul, MN 55107 � i � � I _....... . __. .. :,:. , * � � .au.w ra. �woeo t , � 134( 905 �5 $ i �.r+.ows� weanor weo uuu�o� s.w � n�c�rtn wre , r�u+�.... � .�. u�rtuarw� � N N Q3 00 `02 Y ; �a ` 2 1 2013�ri 1327 w m MW�ESISTB R M11fEROQSTREETNNIE � RaDYYPYDNECT10N .. . x.^T ❑M N QE Z . O3 F> HWY W s w ���� � -•- O'T S9 Uw'f� < COURYID MEIEM REFFAFJKEPOWT � NOIITEBVY Mk1TE/.Sn1EE'�.CORPLII.1R.ptFFA1WE 62 ,� PLEWOOD 007 +Q2,• 291 10 ENGLISH ST . ,,.�+; r .,a� �� - N{fORI �� ����EMI�BER-t • �. ST�TE W9g OLSTAlUB'POSIT(MlY•:CAIVERLICEN]flNUMBER.2 ..,.� .. ��STAIE C1J9g 0.STAM R 1 15 O1 K111117505503 MN A O1 O1 5799103053825 NIN D O1 � raeron: �u.�c;�retwoaF.wn w.eoFUmx .ru.��ves,.r,�e.vsn wreoFeirtre+ rnc,on: 03 PETER MICHAEL DAVIS 06 21 61 SENAYIT TEWELDE SBHATU 02 12 79 �YIU"IFA �OW�filf ORNQ MSINCT.��[DRE55 OIt�AOLT RESTItlLT MAJKR O1 8565 JEWEL AVE N X; O1 4881 HELENA RD N O1 11 � �.,�.,�� A�.���.m � O1 STILLWATER 55082 ST PAUL 55128 O1 RCOMlD 3S SE% EMT g/�oE EOCT /.M6�f. EJEC! BU SEY �A,„pp,,i�� S�t EOPI B.�iE EOPT NqpAG S,ECT �y g� �µp O1 �`� M �4 "� 04 06 05 N =-Y- F �4 "�04 O1 05 C O1 KCMI TYPE ORU6 T4E TDIqSP T11u1&POR! A4�BUlAMC6SERJICfi RUNNVMOER `fiCll IYVE O0.U6 IYPE TON06P TW.VSPOIIT I�M�INANCEBERNC! RUMMAREA �� 98 N� 98 N�. O�R +'�: 98 l�s' 98 y: o� MApLEW00D FI 1300454 �,.,.. -.,.,..: >.�„�. ,. ,. .. . ,.,. �r...a� - .,....:.. .... . . , .. .. .....:: . .. . .. . . �: CGQIP OMrT1ERIMAIE RME . OWNiRNWB FlRE OCCW O1 ST PAUL REGIONAL WATER SRVS. N SENAYIT TEWELDE SBY,ATU N 02 v�mm �ooFess raxFO � �ooness TomEO vEntrv 02 1900 N RICE ST Y, a4881 HELENA RD Y O1 VEMUSE GTY,BTATEIIP VAIMB OWECf � G1Y.STAIF.2P YULUNO OM1ER VE4UiE O1 ST PAUL, MN 55113 �iC` 03 ST PAUL, MN 55128 "'N 03 O1 DMULOC MNtE NOpEt YEM t0�01t 'MVtE MCOEI YFAR COLOR CMOLOC O1 FORD F25 200 BLU • TOYT CAM 001 SIL 11 DM08EV VIATE� �TitEO YEM9EG sE�[NCEOFE�'n9 u05T�NPwE1�xT pu7El STliEO YFJ1NqE0 ��OF�+ff �m ypyTµ�py�. �g�r 04 931650 NIN 014 O1 � O1 " 969CCA MN 013 O1 O1 O1 05 INSWU+ICE POUCYMUWER INgypAHCE�II'NT]) PO:IGYNUIlER � , SELF INSURED UNKNOWN FARMERS UNKNOWN :� s� ...... .. . .. , . CARGO HKMAT WNVED NSECTI�N� PWPWO(3Ei WfNED NA2MAT JJiGOBDv TvvE ruc IF ACCIDENT INVOWED A COMMIERCULL MOTOR VEHICIE,SCHOOL BUS,OR HEAD START BUS � rme - � REMEMBER TO NOTIFY THE STATE PATROL(roqulred undar M9 169J83 end�69.451�). � � COMAIENCIKVEIYLLEMlYBER+.-aIOIORCIRFIFAN�MF. DOTNUkBER G0IAERCi�LVEMICI.ENUYlER2.MDTORGIIRIERNWE DOTNtNfER IM63ENOENSiNVMELSE3 � � LMR POSi1!CAi:OF&RTN 3IX TVPE U9E NRBAA E�Ci IWSEV T0f1061'TN/.VSPORT . . .... SENAIT TESFAI GHEBRAY 3/2�/ g�..s �esu+vx� 02 03 F 04 04 O1 05 C Y, O�a MAPLEWOOD FI �"3�54 �� .we s�rsv� ' auH rw�x Don�+ 0� �ue aere�c� m:N nYaaeen Qonen .....,._......-. .<.. .>..._., .,... .. ..... ..... ............ �....... v^NriEP Oi OTHER MM�1GE0 PFd'ERTY�NOOEbLIW^I0Y OF�W.C{U RtOG(i(LYAMLVpt�'ELLOn?AO MUMBER(9) D�M�C.EO PRCPERTV I YELLOW TM HUI.BEF . ,.1..... ... ..... .... .. .........._. _..... ��...,.... .... ..�...«...: :v': ACGTYP >Z ��NMMATVE. zS �EVIGE ;� ; e- � O1 v` �`s� t O1 _._ sc�aeus �� 4:� _ .a� � �� VEHICLES 2 AND 3 WERE STOPPED IN RIGHT LANE AT �; 03 � , _.. �TM ; N -: THE RED LIGHT OF EB HWY 36 AT ENGLISH ST. BOTH �s � DRZV.ERS. 2 AND 3 STATED THE SEMAPHORE WAS .R�D AND � ��� O1 " �' O1 I ���; THEY WERE ABOUT 6 TO 8 CARS IN LINE IN THE RIGHT �g °N°R1D�E �*:� ;t;' LANE STOPPED. DRZVER OF VEF{ICLE 1 STATED..HE WAS...;: wrwn jQ �� SLOWING DOWN IN THE RIGHT LANE AND WAS GETTING i Q� rvveocw:"'; ?'READY TO"TURN/EXIT TO THE RIGHT TURN I:ANE'TO"TAKE ; ��,. . �..� .t� v�o g$ �'s a�` SB 'ENGLISH ST. __ _ s�; ,`nn EB HWY 36 > _ _._ � �>; ?f. . �f,. �� ' Unit 1 ��i�p —�nil 3— �i DRIVEA.1 STATED HE_b.RIEEI,X...L00KED..DOWN,..THEN . �x:+�R� #��. ,_._._ ,� ..._.r_ ? LOOKED UP AND SAW STOPPPED TRAFFZC ZN THE RIGHT ;t �� �; �—'�"", '` �, � � ; LANE. THERE WAS.A HIGH-SPEED.IMPACT...BASED:.ZN THEz>,';�1 Z '`° VERY SEVERE DAMFIGE TO �/EHICLE 2. THERE WAS NO z?:"s .�Y � "�u" '�� �^� EVIDENCE OF BRAKING AND THERE WERE' 'GOUGE' MARKS ,.> 03 '� �- INDICATING A HIGH SPEED CRASH. VEHICLE 1 WAS � ucHr aownr ;'; } " IMPAILED INTO VEHICLE 2'S REAR END . AFTER ;� c O1 /�/pT TO SCALE' �- ����INITIAL..IMPACT,..VEHICLE..2 SLAMMED INTO_VENICLE 3 ;,; �� �a VEHICLE 2 HAD SEYERE (continued on attached t.. *� :i i�} pdQe� _ ._. _ _ _ _. `- N , .: uMwuu �; " :' PDCIJA .., :y .... .. .. . .. . .. . .......... . .... .... . O 1 �:;' :� . Y. �1 .......... . .... ,.... .. ..... .. . ... ... .. . ........ ,. . OFFICERlW1KNAI.EAVO�E� AGfNGY PA'f1KJLSf�IiON 6TATEPATROI O LCCN. NONE ROBB J RAMACHER 390 State Patrol 4460 �y�pFF p o,�R � M i i � Case#: 13400905 " Report Date:Z/6/2013 Accident Narrative,continued: REAR END DAMAGE. OCCUPANTS OF VEHICLE 2 WERE TAKEN TO REGIONS HOSPITAL FOR POSSIBLE INJURIES. NO OTHER INJURIES REPORTED. CLEAR/DRY ROADS. NO WITNESSES ON SCENE. __ _ .... � _ ; �ocxc�uer+a a�noeo �e �%«a,.�� ..ts � ... .,°^ �._ � .�� . ..�. � A 13400905 ' �� �= A ,��� s -�, , � wxnno�aux ruevaoa veN�cres 1ca�o � o� seu� -Morrtn onrc v�+ � �v,r imarTe�.• .. ; w c,u: m RfAft[SYSTFJ: NOUTENVMBERORSTNEE7NAME ' * RJ/�pW�YqREGTpN �� �.��T n O N E Q u1tfR6ECIqM� OR -.- �j� S9 SW OF� < ON S W W u COIMT�NO � INTELEM fHPEREN�?OINf RWTES�'S RWTE(S�AEET.CORPIWIT,piFFATUNE S„� +-. ' ,�.i.k.�r' 'Y 3..:.Ffi: :7 4AA�.. �� � .... ,, . .. .. ._�. . .�. � .�: � , - . . . - � . . x . , - .. � � � - .:..,�..r.r . .. .. , .... .. po� POS�iqN ONVE�UCENSENU�6ER•t STATE MS9 OLlTAlU3 t P09111p1 CRNFR:IGEILIENU48ER-7 $T�TE ClA1S 0.51AIU8 RACION 1 O1 S529137295516 MN D Ol fACipq1 M�MEIFWB�.MIODLEWT� GATEOFlIPTH �.N�MEIFWST.MI00L[.lAbn� D�TEOFNRTM fi�GiORt SCOTT CHRISTOPHER BARRETT 03 10 69 w+weR •ooncat oawar �earn�r. ,�ooawa onvwu asrwcr wrr�uut 11 6487 PHEASANT HILLS N�. O1 p�ry� plY.'3TRTLZ� �:GTY.STATE.➢P PHYSCL O1 LINO LAKES 55038 O1 � � �P'�T '��• •�'"` F'�"` W�V �� s�" TM�E� USEEEOPT AlilBh6 EJECT MJ9EV 0.l'.OMND M . 04 04 06 05 N Koa rve d+u� me ro wso rn.reroar �nce sea,nc� wx r�a aaa rve orrtw irne m i+osa rnn.Wwonr we�xu.ce aeav� rtuw rnre�a � 9 8 I�'� 9 8 N-; o�R ,��. ,�T o�a , . .»_-, .. „ ...W .s=_r.,� .:.. ,...,. . . ..:::.., . ;.,, .. . ,.. . . OCCJP 0'NNlRtMYE �FRE ONNEftNMtE ME OCCF 07 SCOTT CHRISTOPHER BARRET'� N w�mm �oon� rovrFn �ooaess iov�o varv O1 6487 PHEASANT HILLS Y VEXUSE CffY.BTATE.LP PAlINO DIRECT .OIY,ST�IF.�P NAUNO OWECf VEMUiE O1 LINO LAKES, MN 55038 "I�1` 03 " """ � o�w�x wiee e�oae� rew co�oa �wxe +roo[t rEU+ ca.oa wro�oc 05 CHEV SLV 200 GRY DM6 SEV RATE/ ST RE6 `.'EN3 REG �ENt4 Ov E�hl9 WST ruPU EVFNi�:�PUTE� ST MEG vFNt REG � K�NC!Oi�t 405T MNM I�G SEV �2 TME536 NIN 013 O1 � O1 Si�.INSUMNGE PIXIGYNUMBER WSUNNCEhNNT71 P0.IGYNUI.�EH w . PROGRESSIVE 9000129334 x� T .._,.. . .. - . . .. . . ., .. c�nco wvr.vs wa�o �we�enon• earwoos• ... . �wwEV wae.wT saeneov rvrE r�+c IF ACCIDENT INYOLVED A COMMERCUL MOTUR YEHICLE,SCHOOL BUS,OR HEAD 9TART BUS vuc rws � - ' REMEMBER TO NOTIFY THE 9TATE PATROI(nqulnd untl�r MS 169.783 snd'169.t311). � � COwAERGl4 VENICLF NIK18£M 1.1OIOR W WIEA tUME OOT WNOEn CAMAERC4LVEMIGlE NUMBER 2.MDTOR CMRiEP tNbE DOT Nu.fER .. ..... .. .. .... .. . . . . . . .. . . .... . . . ..... .... IMSSENGERS I WIlNC9SF3 . _.._ ..UNR POSTN OA�Of&RTM SIX TYPE WE NABl�(3 EJECT UU SEV TO MOF.1'TRANSiORT � . ��y Mt83�nVIGE filNhianFA QOTl4 Oµb ANBSERVICE � flUNM1�9ER �OT!,FA O� AMB SERVICE RUN NlF.6ER QOTIIER ...... ..... ......... ...........,..«�.. - .v..e..- I OWNFJIOF OTNEA D4AAGFD PI1M'EI(iYANO OESCRIP'10'10F W�NC�U P�VEFf1Y�NPOR"ELL(Tt/.Mi MII,�FR(91 ��WGFD PROPERfY IYELLDN TAO NtRBER ..... 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